Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder

Abstract

Background Alcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers. Methods Using an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers’ capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions. Results Facilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team. Conclusions A large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD.

Patient perspectives on emergency department initiation of medication for alcohol use disorder

“…34 Recent evidence suggests that initiating MAUD in the ED is similarly feasible, but introducing AUD treatment in the acute care setting poses unique challenges for patients and providers. 12,27 This is the first study to assess NTX initiation in the ED for AUD from the patients' perspective and it delineates several specific barriers and facilitators that patients perceive when offered treatment.…”

“…Prior to this study, we completed an investigation of ED staff perspectives on NTX initiation from the ED and used the BCW framework to guide the initial implementation of our NTX pathway. 27…”

SAEM GRACE: Anti‐craving medications for alcohol use disorder treatment in the emergency department: A systematic review of direct evidence

“…Other barriers included staff bias, and the feeling that treating individuals with AUD is complex. 48 ED provider stigma may also be present in some cases. 49 Given the paucity of direct evidence on this topic, awareness for funding resources and recognition of gaps in medical training and clinical care should be identified for conditions frequently presenting to the ED.…”

Emergency department initiation of pharmacotherapy for alcohol use disorder: A retrospective cohort study

“…10 In practice, EM physicians cite several barriers to initiating mAUD, including limited familiarity with prescribing, difficulty identifying appropriate candidates, a sense of futility, and stigma. 11 The absence of clear benefit for mAUD in the ED may also be an impediment to practice adoption. 12 However, though ED-specific evidence is limited, literature supports mAUD in other settings, 4 and the overall risk of harm associated with first-line mAUD, when appropriately prescribed, is low.…”